| NPI | 1285041921 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL6971) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 1597-39) |
| Enumeration Date | 2014-07-15 |
| Last Update Date | 2023-07-24 |