| NPI | 1902932668 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 224P00000X Prosthetist (Licence: MI CPO02962) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer |
| 222Z00000X Orthotist (Licence: MI CPO02962) | |
| Enumeration Date | 2007-02-26 |
| Last Update Date | 2023-01-12 |