| NPI | 1609111483 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL2561) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: FL PT27433) |
| Enumeration Date | 2012-12-04 |
| Last Update Date | 2023-01-20 |