| NPI | 1912453101 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TX AT7578) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: TX 724561) |
| Enumeration Date | 2016-08-29 |
| Last Update Date | 2020-01-11 |