| NPI | 1821468349 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MD A00747) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: DE j3-0000516) |
| Enumeration Date | 2015-09-26 |
| Last Update Date | 2015-09-26 |