| NPI | 1386173581 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NC LAT-3111) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: SC 2119) |
| Enumeration Date | 2017-06-09 |
| Last Update Date | 2018-06-21 |