| NPI | 1871587675 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 0126002711) |
| Additional Taxonomies | 2251S0007X Physical Therapist, Sports (Licence: VA 2305003798) |
| 2251S0007X Physical Therapist, Sports (Licence: MD 16418) | |
| 2251S0007X Physical Therapist, Sports (Licence: DE 1016) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: DE j30000104) | |
| Enumeration Date | 2005-09-07 |
| Last Update Date | 2020-07-03 |