| NPI | 1619433505 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MO 2026008118) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-02-15 |
| Last Update Date | 2026-03-05 |