| NPI | 1710452644 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NE 959) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NJ 95724) |
| Enumeration Date | 2018-10-08 |
| Last Update Date | 2019-12-03 |