| NPI | 1700852126 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: KY AT603) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: OH AT-002127) |
| 246ZC0007X Specialist/Technologist, Other Surgical Assistant (Licence: KY SA188) | |
| Enumeration Date | 2006-02-25 |
| Last Update Date | 2009-02-27 |