| NPI | 1124161310 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OH AT005694) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IN 36001202A) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 945-039) | |
| Enumeration Date | 2007-02-15 |
| Last Update Date | 2018-12-14 |