| NPI | 1376079574 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT002991) |
| Additional Taxonomies | 405300000X Prevention Professional (Licence: GA AT002991) |
| Enumeration Date | 2017-05-08 |
| Last Update Date | 2017-05-08 |