| NPI | 1093172199 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: LA ATH.J00202) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: SC SC532593) |
| Enumeration Date | 2016-01-20 |
| Last Update Date | 2022-01-21 |