| NPI | 1831616739 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: IL 096004486) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MO 2017025263) |
| Enumeration Date | 2017-08-23 |
| Last Update Date | 2017-08-28 |