| NPI | 1942350954 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: GA AT001259) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL 3434) |
| Enumeration Date | 2007-01-11 |
| Last Update Date | 2019-05-23 |