| NPI | 1619591450 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 246ZX2200X Specialist/Technologist, Other, Orthopedic Assistant |
| Enumeration Date | 2020-06-07 |
| Last Update Date | 2020-06-07 |