| NPI | 1518920495 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 224L00000X |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OR AT-AT-730880) |
| Enumeration Date | 2006-04-11 |
| Last Update Date | 2019-03-15 |