| NPI | 1194145755 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MN 2549) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: TX AT1030) |
| 2255A2300X Specialist/Technologist Athletic Trainer (Licence: FL AL358) | |
| Enumeration Date | 2014-04-22 |
| Last Update Date | 2014-04-22 |