| NPI | 1306834809 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207P00000X Emergency Medicine (Licence: OH 34.010641) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN AT 0000000793) |
| Enumeration Date | 2005-10-10 |
| Last Update Date | 2012-08-10 |