| NPI | 1023122884 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: KY AT384) |
| Additional Taxonomies | 146L00000X Emergency Medical Technician, Paramedic (Licence: KY 3359P) |
| Enumeration Date | 2006-08-18 |
| Last Update Date | 2025-09-11 |