| NPI | 1962670307 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: FL AL5565) |
| Additional Taxonomies | 174400000X Specialist (Licence: KY AT1210) |
| Enumeration Date | 2008-02-20 |
| Last Update Date | 2020-03-18 |