| NPI | 1407368111 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: TX AT6772) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: 2000025610) |
| Enumeration Date | 2017-11-03 |
| Last Update Date | 2021-12-14 |