| NPI | 1811969462 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: 039126002) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: CA AT 3717) |
| Enumeration Date | 2006-02-07 |
| Last Update Date | 2025-09-11 |