| NPI | 1356628614 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NJ 25MT00086700)  | 
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RT004995)  | 
| Enumeration Date | 2011-11-14 | 
| Last Update Date | 2011-11-14 |