| NPI | 1801889548 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AZ 0570) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RT002200A) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 0126000994) | |
| Enumeration Date | 2005-08-29 |
| Last Update Date | 2007-07-08 |