| NPI | 1881754596 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN ATC125) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: TN PTA3963) |
| Enumeration Date | 2006-12-11 |
| Last Update Date | 2025-09-11 |