| NPI | 1124422993 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: UT 11878522-4810) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: OH 003407) |
| 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NM AT640) | |
| Enumeration Date | 2014-10-22 |
| Last Update Date | 2021-07-23 |