| NPI | 1811248024 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 174400000X Specialist (Licence: MN 2413) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MN 2413) |
| Enumeration Date | 2012-09-27 |
| Last Update Date | 2017-11-13 |