| NPI | 1477823573 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: 069402691) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: TX AT1217) |
| Enumeration Date | 2012-01-05 |
| Last Update Date | 2017-01-04 |