| NPI | 1215183819 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 0126000729) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: SC 1008) |
| Enumeration Date | 2008-08-14 |
| Last Update Date | 2019-09-10 |