| NPI | 1649774027 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL 6784) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MA 3215) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NY 004274) | |
| Enumeration Date | 2018-03-21 |
| Last Update Date | 2023-11-16 |