| NPI | 1609203850 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 172V00000X Community Health Worker |
| 225100000X Physical Therapist | |
| Enumeration Date | 2013-10-02 |
| Last Update Date | 2019-07-22 |