| NPI | 1386099349 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MS AT0797) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: OH 183551) |
| Enumeration Date | 2016-04-27 |
| Last Update Date | 2019-11-10 |