| NPI | 1134785728 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: 2000032108) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AL 2150) |
| Enumeration Date | 2019-05-20 |
| Last Update Date | 2019-05-20 |