| NPI | 1508137308 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: AR AT 387) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: AR 21470) |
| Enumeration Date | 2012-01-25 |
| Last Update Date | 2014-04-09 |