| NPI | 1689262644 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NC LAT-5302) | 
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TX AT8466) | 
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TX AT8522) | |
| Enumeration Date | 2021-01-05 | 
| Last Update Date | 2025-10-06 |