| NPI | 1013325323 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TX AT6951) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: KS 24-00804) |
| Enumeration Date | 2014-07-30 |
| Last Update Date | 2017-04-17 |