| NPI | 1629447826 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RT004155) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NJ 25MT00155000) |
| Enumeration Date | 2015-09-17 |
| Last Update Date | 2021-01-04 |