| NPI | 1770991564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2081S0010X Physical Medicine & Rehabilitation, Sports Medicine (Licence: PA RT005890) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA rt005890) |
| Enumeration Date | 2014-07-24 |
| Last Update Date | 2023-11-24 |