| NPI | 1912218603 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WA A1 0047296) |
| Additional Taxonomies | 2251X0800X Physical Therapist, Orthopedic (Licence: WA PT00003908) |
| Enumeration Date | 2010-06-28 |
| Last Update Date | 2010-06-28 |