| NPI | 1912183674 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: WV AT001129) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: PA RT004078) |
| Enumeration Date | 2008-01-12 |
| Last Update Date | 2018-12-14 |