| NPI | 1144845736 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TX BP10082423) |
| Additional Taxonomies | 208000000X Pediatrics (Licence: KS 94-10381) |
| Enumeration Date | 2020-06-10 |
| Last Update Date | 2023-08-24 |