| NPI | 1700163623 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: KY AT1311) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: PA RT004559) |
| Enumeration Date | 2011-11-06 |
| Last Update Date | 2021-03-09 |