| NPI | 1568933224 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 1308-39) |
| Additional Taxonomies | 2081S0010X Physical Medicine & Rehabilitation, Sports Medicine (Licence: WI 1308-39) |
| Enumeration Date | 2018-12-06 |
| Last Update Date | 2021-09-22 |