| NPI | 1275946998 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IA 000728) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IN 36002200A) |
| Enumeration Date | 2014-06-10 |
| Last Update Date | 2018-03-17 |