| NPI | 1659944841 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 163W00000X Registered Nurse (Licence: CA 95414155) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: 090202007) |
| Enumeration Date | 2021-07-23 |
| Last Update Date | 2025-03-31 |