| NPI | 1497122881 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 0126003666) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MI 2601001718) |
| 146N00000X Emergency Medical Technician, Basic (Licence: MI 3203056420) | |
| Enumeration Date | 2015-09-01 |
| Last Update Date | 2025-12-15 |