| NPI | 1730148420 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NJ 25MT00139800) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NY 67 000767) |
| Enumeration Date | 2006-03-21 |
| Last Update Date | 2014-07-19 |