| NPI | 1013494319 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MD A0001358) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL5352) |
| Enumeration Date | 2018-07-19 |
| Last Update Date | 2021-09-08 |