| NPI | 1639284714 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 246ZS0410X Specialist/Technologist, Other, Surgical Technologist (Licence: 07-0817) |
| Enumeration Date | 2006-08-20 |
| Last Update Date | 2008-09-11 |