| NPI | 1114303401 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225500000X Specialist/Technologist (Licence: MD 18753MD) |
| Additional Taxonomies | 171W00000X Contractor (Licence: MD 18753MD) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MD 18753MD) | |
| Enumeration Date | 2015-08-10 |
| Last Update Date | 2015-08-10 |