| NPI | 1588075121 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: ID AT-642) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NC LAT-2518) |
| Enumeration Date | 2014-05-16 |
| Last Update Date | 2020-09-02 |