| NPI | 1659704492 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 2556) |
| Additional Taxonomies | 246ZC0007X Specialist/Technologist, Other, Surgical Assistant (Licence: MN 19-0604) |
| Enumeration Date | 2013-08-15 |
| Last Update Date | 2020-02-07 |