| NPI | 1326204348 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: OR AT10145051) |
| Additional Taxonomies | 246ZX2200X Specialist/Technologist, Other Orthopedic Assistant (Licence: OR 050802325) |
| Enumeration Date | 2008-07-29 |
| Last Update Date | 2023-06-23 |