| NPI | 1730506106 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 246Z00000X Specialist/Technologist, Other (Licence: IL 003962) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NY 002488) |
| Enumeration Date | 2014-03-24 |
| Last Update Date | 2015-06-18 |