| NPI | 1053585828 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant |
| Enumeration Date | 2008-04-14 |
| Last Update Date | 2013-09-04 |