| NPI | 1275064693 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MI 2601001712) |
| Enumeration Date | 2017-03-27 |
| Last Update Date | 2021-01-14 |