| NPI | 1386345056 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| Enumeration Date | 2023-03-10 |
| Last Update Date | 2023-03-10 |