| NPI | 1174073407 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NJ 25MT00253100) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RT006824) |
| Enumeration Date | 2016-10-11 |
| Last Update Date | 2025-03-25 |