| NPI | 1710490644 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL62) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: FL PTA18764) |
| Enumeration Date | 2017-11-14 |
| Last Update Date | 2017-11-14 |