| NPI | 1740945567 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: NY 002282-1) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: NY 447922) |
| Enumeration Date | 2021-11-05 |
| Last Update Date | 2021-11-05 |