| NPI | 1114995503 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: CO AT.0001317) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096001502) |
| Enumeration Date | 2006-03-10 |
| Last Update Date | 2015-07-17 |