NPI | 1972661130 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 1803) |
Additional Taxonomies | 111NS0005X Chiropractor, Sports Physician (Licence: MN 4582) |
111NS0005X Chiropractor, Sports Physician (Licence: SD 979) | |
Enumeration Date | 2006-12-04 |
Last Update Date | 2025-09-11 |