| NPI | 1568851467 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NJ 25MT00153200) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NY 002016-1) |
| Enumeration Date | 2015-01-15 |
| Last Update Date | 2015-08-20 |