| NPI | 1174079057 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MS AT-1054) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AR AT846) |
| Enumeration Date | 2016-08-30 |
| Last Update Date | 2023-04-01 |