| NPI | 1659671980 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: ND 953-22) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MI 2601001062) |
| Enumeration Date | 2010-11-03 |
| Last Update Date | 2023-08-15 |