| NPI | 1417456104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: 2000033002) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: CA E127837) |
| Enumeration Date | 2018-02-08 |
| Last Update Date | 2025-08-01 |