| NPI | 1962611913 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: ND 183-98) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MN 1616) |
| Enumeration Date | 2007-05-22 |
| Last Update Date | 2007-07-08 |