| NPI | 1316240278 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: CO 917) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: CO 052249) |
| Enumeration Date | 2010-12-15 |
| Last Update Date | 2010-12-15 |