| NPI | 1033179346 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NE 312) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: NE 13052) |
| Enumeration Date | 2006-03-23 |
| Last Update Date | 2022-07-21 |