| NPI | 1578229761 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2021046883) |
| Additional Taxonomies | 2083S0010X Preventive Medicine, Sports Medicine (Licence: MI 2601001551) |
| Enumeration Date | 2021-11-11 |
| Last Update Date | 2022-04-25 |