| NPI | 1740792951 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: KY 1661) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer |
| Enumeration Date | 2017-10-27 |
| Last Update Date | 2021-02-28 |