| NPI | 1205301124 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL 5743) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: KS 24-01215) |
| Enumeration Date | 2018-10-07 |
| Last Update Date | 2019-10-07 |