| NPI | 1275048001 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: KS 24-01211) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2017022903) |
| Enumeration Date | 2017-12-01 |
| Last Update Date | 2017-12-01 |