| NPI | 1275885287 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MA 2387) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: RI AT00306) |
| Enumeration Date | 2012-10-15 |
| Last Update Date | 2014-10-28 |