| NPI | 1386425718 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT001563) |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant |
| Enumeration Date | 2023-10-11 |
| Last Update Date | 2023-10-11 |