| NPI | 1114329455 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT002782) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL4216) |
| 246ZX2200X Specialist/Technologist, Other, Orthopedic Assistant | |
| Enumeration Date | 2014-09-18 |
| Last Update Date | 2016-05-30 |