| NPI | 1801259064 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096.002039) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IA 00334) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AZ 0392) | |
| Enumeration Date | 2016-04-04 |
| Last Update Date | 2016-04-04 |