| NPI | 1598819807 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MA 1813) |
| Additional Taxonomies | 225000000X Orthotic Fitter (Licence: MA CFO03229) |
| Enumeration Date | 2007-01-23 |
| Last Update Date | 2009-10-07 |