| NPI | 1023137825 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 1172) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: MN 244106) |
| Enumeration Date | 2007-03-29 |
| Last Update Date | 2025-09-11 |