| NPI | 1235142779 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: AZ 0370) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: IL 096.002701) |
| Enumeration Date | 2006-08-15 |
| Last Update Date | 2016-04-11 |