| NPI | 1831467893 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: AZ ATR-001492) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL3061) |
| Enumeration Date | 2011-12-06 |
| Last Update Date | 2021-08-23 |