| NPI | 1083727739 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NY 709) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: RI AT00244) |
| 146M00000X Emergency Medical Technician, Intermediate (Licence: RI EMT14833) | |
| Enumeration Date | 2006-08-16 |
| Last Update Date | 2016-05-06 |