| NPI | 1912381245 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TN 1680) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: TN 30732) |
| Enumeration Date | 2015-07-16 |
| Last Update Date | 2015-07-17 |