| NPI | 1124016043 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RT000189A) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NJ 25MTOOO47700) |
| Enumeration Date | 2005-10-13 |
| Last Update Date | 2007-07-08 |