| NPI | 1114083854 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NJ 25MT00145500) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN 1043) |
| Enumeration Date | 2006-12-28 |
| Last Update Date | 2008-09-04 |