| NPI | 1679054035 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: 2000031468) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 01260030039) |
| Enumeration Date | 2018-08-23 |
| Last Update Date | 2018-08-23 |