| NPI | 1679966279 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 0126002079) |
| Enumeration Date | 2015-03-06 |
| Last Update Date | 2021-04-23 |