| NPI | 1609480631 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MD A01405) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NY 003983) |
| Enumeration Date | 2020-09-08 |
| Last Update Date | 2021-08-03 |