| NPI | 1134265242 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MA 1225) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NY 000347) |
| Enumeration Date | 2007-01-29 |
| Last Update Date | 2007-07-08 |