| NPI | 1053041202 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NC LAT-5702) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 0126003244) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RT007833) | |
| Enumeration Date | 2022-06-11 |
| Last Update Date | 2025-10-08 |