| NPI | 1356887608 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: ME AT573) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: ME 28430) |
| Enumeration Date | 2017-01-10 |
| Last Update Date | 2017-01-10 |