| NPI | 1962067611 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 222Q00000X Developmental Therapist |
| 225400000X Rehabilitation Practitioner | |
| 227800000X Respiratory Therapist, Certified | |
| Enumeration Date | 2019-05-08 |
| Last Update Date | 2019-05-08 |