| NPI | 1912643875 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: PA MSG013817) |
| Enumeration Date | 2022-05-12 |
| Last Update Date | 2022-05-12 |