| NPI | 1609835099 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: MA 843514) |
| Enumeration Date | 2006-03-22 |
| Last Update Date | 2007-07-08 |