| NPI | 1679552442 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MI 2601000096) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL1904) |
| Enumeration Date | 2006-01-11 |
| Last Update Date | 2020-12-31 |