| NPI | 1699241695 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 103TE1100X Psychologist, Exercise & Sports |
| 172V00000X Community Health Worker | |
| 174H00000X Health Educator | |
| Enumeration Date | 2018-10-17 |
| Last Update Date | 2018-10-17 |