| NPI | 1760593123 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN 0333) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: TN 5430) |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2009-02-18 |