| NPI | 1689156762 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: 2000036454) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: TX E1329301) |
| Enumeration Date | 2018-09-05 |
| Last Update Date | 2019-06-13 |