| NPI | 1053723494 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OH AT.003568) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AZ 1012) |
| Enumeration Date | 2014-05-20 |
| Last Update Date | 2014-05-20 |