| NPI | 1720266216 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2016022071) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL1968) |
| Enumeration Date | 2008-02-06 |
| Last Update Date | 2023-09-05 |