| NPI | 1538361795 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OK 426) |
| Additional Taxonomies | 246Z00000X Specialist/Technologist, Other (Licence: OK 426) |
| Enumeration Date | 2007-06-01 |
| Last Update Date | 2017-12-14 |