| NPI | 1720015340 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: HI 1905) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: HI AT152) | |
| Enumeration Date | 2006-06-27 |
| Last Update Date | 2015-02-06 |