| NPI | 1255698353 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: CO 1034) |
| Additional Taxonomies | 246Z00000X Specialist/Technologist, Other (Licence: 11-0206) |
| Enumeration Date | 2012-04-13 |
| Last Update Date | 2012-04-13 |