| NPI | 1487628947 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN AT0000001187) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2005003294) |
| Enumeration Date | 2006-02-13 |
| Last Update Date | 2010-01-12 |