| NPI | 1609880590 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 146N00000X Emergency Medical Technician, Basic (Licence: LA B0467966) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: LA J00010) |
| Enumeration Date | 2006-07-28 |
| Last Update Date | 2025-09-11 |