| NPI | 1659822393 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AL 2573) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2019040274) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096004087) | |
| Enumeration Date | 2016-10-18 |
| Last Update Date | 2026-04-08 |