| NPI | 1982838496 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RT005787) |
| Additional Taxonomies | 225000000X Orthotic Fitter (Licence: PA OF000004) |
| Enumeration Date | 2009-05-12 |
| Last Update Date | 2014-04-27 |