| NPI | 1386086189 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AL 1834) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TX AT1982) |
| Enumeration Date | 2013-07-22 |
| Last Update Date | 2016-09-01 |