| NPI | 1649419052 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 163W00000X Registered Nurse (Licence: GA RN225995) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT0011049) |
| Enumeration Date | 2009-02-09 |
| Last Update Date | 2016-05-04 |