| NPI | 1548492630 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL6740) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TX AT7004) |
| Enumeration Date | 2009-08-22 |
| Last Update Date | 2022-09-27 |