| NPI | 1174596514 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: OK 386) |
| Additional Taxonomies | 174400000X Specialist (Licence: TX AT2846) |
| Enumeration Date | 2006-02-08 |
| Last Update Date | 2015-04-17 |