| NPI | 1841705399 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: 2000036585) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: E2031440) |
| 1710I1002X Military Health Care Provider Independent Duty Corpsman | |
| Enumeration Date | 2017-12-06 |
| Last Update Date | 2020-06-30 |