| NPI | 1154788800 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IA 079339) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 0126002021) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 2757) | |
| Enumeration Date | 2016-01-26 |
| Last Update Date | 2016-01-26 |