| NPI | 1578971636 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OK 911) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN 1261) |
| Enumeration Date | 2014-07-31 |
| Last Update Date | 2016-05-02 |