| NPI | 1104269109 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TX AT5688) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MA 2306) |
| Enumeration Date | 2013-04-10 |
| Last Update Date | 2014-11-26 |