| NPI | 1497250302 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: IL 096.004640) |
| Additional Taxonomies | 164W00000X Licensed Practical Nurse (Licence: IL 043.116227) |
| Enumeration Date | 2018-03-25 |
| Last Update Date | 2018-03-25 |