| NPI | 1205373651 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WA A161652834) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AZ ATR-009181) |
| Enumeration Date | 2017-01-24 |
| Last Update Date | 2025-11-18 |