| NPI | 1578891800 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AZ 0260) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: AZ 57112) |
| Enumeration Date | 2009-11-24 |
| Last Update Date | 2009-11-24 |