| NPI | 1366915464 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NE 1169) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL5725) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-01-10 |
| Last Update Date | 2023-06-27 |