| NPI | 1811927635 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT000130) |
| Additional Taxonomies | 224L00000X (Licence: GA C50456) |
| Enumeration Date | 2006-07-04 |
| Last Update Date | 2019-08-13 |