| NPI | 1972212926 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN AT0000000761) |
| Additional Taxonomies | 225000000X Orthotic Fitter |
| Enumeration Date | 2022-11-18 |
| Last Update Date | 2022-11-18 |