| NPI | 1194125047 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OK 1406) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2013006628) |
| Enumeration Date | 2014-08-28 |
| Last Update Date | 2025-12-31 |