| NPI | 1487100988 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: TN 11609551) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer |
| Enumeration Date | 2016-08-25 |
| Last Update Date | 2020-12-10 |