| NPI | 1699743948 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: AZ 0564) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: ID AT-266) |
| 2255A2300X Specialist/Technologist Athletic Trainer | |
| Enumeration Date | 2006-03-12 |
| Last Update Date | 2007-07-08 |