| NPI | 1588094643 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WV AT001120) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WV PT002676) |
| Enumeration Date | 2013-11-26 |
| Last Update Date | 2017-04-28 |