| NPI | 1114989647 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: RI AT00166) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MA 1597) |
| Enumeration Date | 2006-04-02 |
| Last Update Date | 2007-07-08 |