| NPI | 1821018987 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 50-039) |
| Additional Taxonomies | 246Z00000X Specialist/Technologist, Other (Licence: WI 1853-046) |
| Enumeration Date | 2006-07-20 |
| Last Update Date | 2014-05-21 |