| NPI | 1962916395 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 146N00000X Emergency Medical Technician, Basic (Licence: WI 70108769) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Enumeration Date | 2017-11-21 |
| Last Update Date | 2017-11-21 |