| NPI | 1790458495 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WA ATHL.A1.70008337) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: WA PT.PT.70004362) |
| Enumeration Date | 2021-07-28 |
| Last Update Date | 2025-06-05 |