| NPI | 1043497787 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NY 000499) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: DE J3-0000406) |
| Enumeration Date | 2008-01-24 |
| Last Update Date | 2017-01-06 |