| NPI | 1912961053 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IN 36000741A) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: IN 06001886A) |
| Enumeration Date | 2006-04-14 |
| Last Update Date | 2018-03-17 |