| NPI | 1750495586 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 246Z00000X Specialist/Technologist, Other (Licence: CO 756) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: ID AT-271) |
| Enumeration Date | 2006-08-18 |
| Last Update Date | 2016-01-15 |