| NPI | 1154395812 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 174400000X Specialist (Licence: NY 0000171) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NY 000058-01) |
| 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: NY 00000171) | |
| Enumeration Date | 2006-02-17 |
| Last Update Date | 2010-05-26 |