| NPI | 1720573785 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic |
| Enumeration Date | 2018-06-22 |
| Last Update Date | 2022-05-05 |