| NPI | 1770556128 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AZ 0338) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096-002089) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: ID AT-214) | |
| Enumeration Date | 2006-02-08 |
| Last Update Date | 2007-07-08 |