| NPI | 1548716814 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL3804) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 2259) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: CT 1023) | |
| Enumeration Date | 2016-08-28 |
| Last Update Date | 2016-08-28 |