| NPI | 1467099770 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096004123) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2016026851) |
| Enumeration Date | 2019-12-05 |
| Last Update Date | 2019-12-05 |