| NPI | 1023421815 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 0126001837) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: VA B121708507) |
| Enumeration Date | 2014-06-09 |
| Last Update Date | 2014-06-09 |