| NPI | 1417054065 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AL 771) |
| Additional Taxonomies | 246ZS0410X Specialist/Technologist, Other, Surgical Technologist |
| Enumeration Date | 2006-09-17 |
| Last Update Date | 2010-02-15 |