| NPI | 1053834044 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MI 2601001926) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 0126002560) |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| Enumeration Date | 2017-07-21 |
| Last Update Date | 2017-08-15 |