| NPI | 1619434776 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 0126003567) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: SC AT03073) |
| Enumeration Date | 2019-02-25 |
| Last Update Date | 2024-08-11 |