| NPI | 1306303896 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN 2490) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OH AT005729) |
| Enumeration Date | 2019-02-21 |
| Last Update Date | 2022-11-04 |