| NPI | 1023469129 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AZ 1488) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OR AT-AT-10171243) |
| Enumeration Date | 2016-06-29 |
| Last Update Date | 2016-06-29 |