| NPI | 1629298807 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: PA RT003485) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NJ 25MT00078600) |
| Enumeration Date | 2007-04-27 |
| Last Update Date | 2007-07-08 |