| NPI | 1679105944 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208100000X Physical Medicine & Rehabilitation (Licence: IA 099040) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IA 093267) |
| Enumeration Date | 2020-02-05 |
| Last Update Date | 2022-05-17 |