| NPI | 1134694664 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RT007167) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WY 166) |
| Enumeration Date | 2018-10-11 |
| Last Update Date | 2021-10-21 |