| NPI | 1356719512 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MI L949703) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OH AT.003702) |
| Enumeration Date | 2015-09-04 |
| Last Update Date | 2015-12-04 |