| NPI | 1710486071 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MI 2601002686) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NE 1145) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096.005659) | |
| Enumeration Date | 2018-02-01 |
| Last Update Date | 2023-04-13 |