| NPI | 1992027015 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: CA AT 10372) |
| Enumeration Date | 2010-02-16 |
| Last Update Date | 2014-02-19 |