| NPI | 1508948860 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NY 001192) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NJ 25MT00123000) |
| Enumeration Date | 2006-10-19 |
| Last Update Date | 2024-03-21 |