| NPI | 1104885599 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: CT 000489) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NY 001071) |
| Enumeration Date | 2006-03-22 |
| Last Update Date | 2014-01-30 |