| NPI | 1336101435 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 163W00000X Registered Nurse (Licence: MA 269340) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: MA 842787) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MA 1501) | |
| Enumeration Date | 2006-04-04 |
| Last Update Date | 2025-09-11 |