| NPI | 1053830653 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT004138) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RT005805) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NY 002673) | |
| Enumeration Date | 2017-09-14 |
| Last Update Date | 2022-12-05 |