| NPI | 1033496377 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 246Z00000X Specialist/Technologist, Other (Licence: TX #AT5996) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: IL 096003069) |
| Enumeration Date | 2011-11-15 |
| Last Update Date | 2015-03-15 |