| NPI | 1962464313 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NJ 25MT0000434) |
| Additional Taxonomies | 146N00000X Emergency Medical Technician, Basic |
| Enumeration Date | 2006-04-03 |
| Last Update Date | 2010-08-09 |