| NPI | 1184010068 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RT005040) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WV AT001193) |
| Enumeration Date | 2015-04-08 |
| Last Update Date | 2015-04-08 |