| NPI | 1083191837 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NY 003996) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VT 104.0133074) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 0126002623) | |
| Enumeration Date | 2018-07-24 |
| Last Update Date | 2022-12-05 |