| NPI | 1154987667 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 133V00000X Dietitian, Registered (Licence: NY 009927) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NY 002046) |
| Enumeration Date | 2019-05-10 |
| Last Update Date | 2019-09-03 |