| NPI | 1619382306 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 2024-39) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096003420) |
| Enumeration Date | 2014-06-22 |
| Last Update Date | 2019-05-02 |