| NPI | 1558719963 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OH AT004566) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: GA AT002638) |
| Enumeration Date | 2016-05-25 |
| Last Update Date | 2018-03-17 |