| NPI | 1457035990 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OH AT006743)  | 
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN 1614)  | 
| Enumeration Date | 2023-06-14 | 
| Last Update Date | 2023-06-14 |