| NPI | 1124069083 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: ME AT4) |
| Additional Taxonomies | 225700000X Massage Therapist (Licence: ME MT535) |
| Enumeration Date | 2006-06-09 |
| Last Update Date | 2007-07-08 |