| NPI | 1821530270 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: 2000023670) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: TX 729339) |
| Enumeration Date | 2016-11-15 |
| Last Update Date | 2025-10-01 |