| NPI | 1104501527 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: PA RTO000488) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: OH AT006176) |
| 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NY 00429101) | |
| Enumeration Date | 2023-06-21 |
| Last Update Date | 2023-06-21 |