| NPI | 1588657902 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: WI 137-039) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WI 10699-024) |
| Enumeration Date | 2005-08-31 |
| Last Update Date | 2016-11-29 |