| NPI | 1235103763 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: TN 0000001073) |
| Additional Taxonomies | 174400000X Specialist (Licence: FL AL 1441) |
| Enumeration Date | 2006-02-13 |
| Last Update Date | 2008-03-05 |