| NPI | 1336569748 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MN 2419) |
| Additional Taxonomies | 174H00000X Health Educator (Licence: MN 2419) |
| Enumeration Date | 2014-04-24 |
| Last Update Date | 2017-04-06 |