| NPI | 1982165502 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MD A0001627) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: MD 28990) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RT007587) | |
| Enumeration Date | 2019-03-27 |
| Last Update Date | 2025-03-10 |