| NPI | 1699738963 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: FL AL671) |
| Additional Taxonomies | 247100000X Radiologic Technologist (Licence: FL BMO 66516) |
| Enumeration Date | 2006-04-08 |
| Last Update Date | 2022-07-21 |