| NPI | 1083069215 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 2000022401) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: MN E2036958) |
| Enumeration Date | 2016-04-25 |
| Last Update Date | 2016-04-25 |