| NPI | 1083674329 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: NC 2019-01832) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NC 1158) |
| Enumeration Date | 2006-03-23 |
| Last Update Date | 2024-03-12 |