| NPI | 1053708156 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: RI AT00374) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MA 2330) |
| Enumeration Date | 2015-04-16 |
| Last Update Date | 2015-04-16 |