| NPI | 1518934470 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 222Z00000X (Licence: IL 213000239) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Enumeration Date | 2006-03-01 |
| Last Update Date | 2025-09-11 |