| NPI | 1164874715 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 171M00000X Case Manager/Care Coordinator |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: 2000015073) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN AT 0000001766) | |
| Enumeration Date | 2016-07-07 |
| Last Update Date | 2020-10-01 |