| NPI | 1205804895 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096001346) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL1792) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 630039) | |
| Enumeration Date | 2006-03-09 |
| Last Update Date | 2007-07-08 |