| NPI | 1164939179 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096004560) |
| Additional Taxonomies | 246ZX2200X Specialist/Technologist, Other, Orthopedic Assistant (Licence: IL 16-06-30) |
| Enumeration Date | 2017-12-29 |
| Last Update Date | 2017-12-29 |