| NPI | 1548677768 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MA 2708) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: VT 102859) |
| 146N00000X Emergency Medical Technician, Basic (Licence: MA E0904306) | |
| Enumeration Date | 2014-07-21 |
| Last Update Date | 2015-06-01 |