| NPI | 1790757060 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL al411) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: FL pta1272) |
| Enumeration Date | 2006-02-02 |
| Last Update Date | 2025-09-11 |