| NPI | 1356678841 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: FL AL4785) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NJ 25MT00125500) |
| Enumeration Date | 2009-11-04 |
| Last Update Date | 2022-07-21 |