| NPI | 1013451095 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: MA S62236208) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MA S62236208) |
| Enumeration Date | 2016-12-11 |
| Last Update Date | 2016-12-11 |