| NPI | 1922455492 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WI 2156-39) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 2776) |
| Enumeration Date | 2016-05-15 |
| Last Update Date | 2020-05-21 |