| NPI | 1700485505 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IA 080342) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: IA 105325) |
| Enumeration Date | 2020-10-22 |
| Last Update Date | 2020-10-22 |