| NPI | 1891899290 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT001398) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: 040502009) |
| Enumeration Date | 2006-09-07 |
| Last Update Date | 2008-01-31 |