| NPI | 1700079837 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2251S0007X Physical Therapist Sports (Licence: IN 05001844A) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: IN 36000225A) |
| Enumeration Date | 2007-08-22 |
| Last Update Date | 2007-08-22 |