| NPI | 1295112472 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: TX 6280) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: SC 1460) |
| Enumeration Date | 2015-04-27 |
| Last Update Date | 2015-04-27 |