| NPI | 1861552093 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 225500000X Specialist/Technologist (Licence: WI 107-039) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 107-039) |
| Enumeration Date | 2006-12-11 |
| Last Update Date | 2007-07-08 |