| NPI | 1235122789 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: SC 070) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: SC 18106) |
| Enumeration Date | 2005-08-30 |
| Last Update Date | 2023-01-18 |