| NPI | 1316330319 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 1147-39) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MI 2601001392) |
| Enumeration Date | 2015-03-15 |
| Last Update Date | 2015-03-15 |