| NPI | 1629137120 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: VA 0126002684) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NJ 25MT00102600) |
| Enumeration Date | 2006-12-08 |
| Last Update Date | 2018-03-17 |