| NPI | 1801858980 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: CA 840263) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: CA AT 3785) |
| Enumeration Date | 2006-04-04 |
| Last Update Date | 2014-08-04 |