| NPI | 1336617323 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT003569) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AR AT767) |
| Enumeration Date | 2018-11-07 |
| Last Update Date | 2020-04-22 |