| NPI | 1912992702 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 2251S0007X Physical Therapist Sports (Licence: WI 3806) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: WI 234) |
| Enumeration Date | 2005-09-17 |
| Last Update Date | 2007-07-08 |