| NPI | 1154545887 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: SC 070502170) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: SC 843) |
| Enumeration Date | 2007-04-12 |
| Last Update Date | 2008-09-15 |