| NPI | 1194790212 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MS AT0837) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: FL AL1663) |
| Enumeration Date | 2006-02-22 |
| Last Update Date | 2018-05-10 |