| NPI | 1942737556 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: PA RT006593) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic (Licence: PA E3159597) |
| Enumeration Date | 2017-05-12 |
| Last Update Date | 2017-05-12 |