| NPI | 1295105062 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT003026) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: PA 197367) |
| Enumeration Date | 2015-10-05 |
| Last Update Date | 2016-12-08 |