| NPI | 1386812105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: WI 1018-39) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: IL 096002454) |
| Enumeration Date | 2008-02-14 |
| Last Update Date | 2011-04-05 |