| NPI | 1902838808 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: IA 00529) |
| Additional Taxonomies | 146M00000X Emergency Medical Technician, Intermediate (Licence: IA AEMT-11-1000-09) |
| Enumeration Date | 2006-07-07 |
| Last Update Date | 2014-07-01 |