| NPI | 1679085757 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MD A0000679) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Enumeration Date | 2017-10-30 |
| Last Update Date | 2022-08-12 |