| NPI | 1134536881 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA 2000009788) |
| Enumeration Date | 2014-07-15 |
| Last Update Date | 2022-03-30 |