| NPI | 1144588971 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: ID AT-779) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WA A1 60306008) |
| Enumeration Date | 2012-04-30 |
| Last Update Date | 2025-12-18 |