| NPI | 1407492358 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: WI 3124-39) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: PA 0966488) |
| 2255A2300X Specialist/Technologist Athletic Trainer | |
| Enumeration Date | 2019-11-25 |
| Last Update Date | 2023-09-26 |