| NPI | 1902229842 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: VA 0126001589) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: PA RT005108) |
| Enumeration Date | 2014-01-29 |
| Last Update Date | 2024-01-04 |