| NPI | 1689125064 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 58839) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: WI 229319) |
| Enumeration Date | 2016-10-20 |
| Last Update Date | 2016-10-20 |