| NPI | 1508220930 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MS AT0743) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AL 1654) |
| Enumeration Date | 2016-04-12 |
| Last Update Date | 2016-04-12 |