| NPI | 1053718569 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NJ 25MT00211600) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MI 2601001366) |
| Enumeration Date | 2014-11-26 |
| Last Update Date | 2015-09-04 |