| NPI | 1154759793 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: LA ATH.200377) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AL 1480) |
| Enumeration Date | 2013-10-17 |
| Last Update Date | 2014-12-26 |