| NPI | 1619648417 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: RI AT00530) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: CT 000931) |
| Enumeration Date | 2021-09-22 |
| Last Update Date | 2021-09-22 |