| NPI | 1710312657 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TX AT5312) |
| Additional Taxonomies | 171W00000X Contractor (Licence: TX AT5312) |
| Enumeration Date | 2013-09-11 |
| Last Update Date | 2016-11-03 |