| NPI | 1255791166 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MS AT0647) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AL 1041) |
| Enumeration Date | 2016-03-04 |
| Last Update Date | 2016-03-04 |