| NPI | 1548677768 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MA 2708) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MA RN2349708) |
| Enumeration Date | 2014-07-21 |
| Last Update Date | 2024-12-29 |