| NPI | 1316932627 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: PA RT001005A) |
| Additional Taxonomies | 225500000X Specialist/Technologist (Licence: PA RT001005A) |
| Enumeration Date | 2005-09-13 |
| Last Update Date | 2012-01-16 |