| NPI | 1689870396 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MA 1028) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: MA 4035) |
| Enumeration Date | 2007-06-21 |
| Last Update Date | 2025-09-11 |