| 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 |