| NPI | 1619561313 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225200000X Physical Therapy Assistant (Licence: MS PTA4680) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: AL PTA6336) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MS AT0358) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AL 2373) | |
| Enumeration Date | 2021-02-23 |
| Last Update Date | 2021-02-23 |