| NPI | 1063530244 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 183500000X Pharmacist (Licence: MI 5302028811) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MI 5302028811) |
| Enumeration Date | 2007-03-27 |
| Last Update Date | 2019-12-06 |