| NPI | 1356941710 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 051.303261) |
| Additional Taxonomies | 183500000X Pharmacist (Licence: MI 5302412671) |
| Enumeration Date | 2020-10-27 |
| Last Update Date | 2024-06-10 |