| NPI | 1649547480 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IN 36001860A) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT002238) |
| Enumeration Date | 2011-11-22 |
| Last Update Date | 2018-03-17 |