| NPI | 1639373616 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: VA B012663004) |
| Enumeration Date | 2007-06-13 |
| Last Update Date | 2017-03-09 |