| NPI | 1104056316 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096002794) |
| Additional Taxonomies | 246Z00000X Specialist/Technologist, Other |
| Enumeration Date | 2009-07-22 |
| Last Update Date | 2015-04-03 |