| NPI | 1972259646 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2022034395) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096005476) |
| Enumeration Date | 2022-02-22 |
| Last Update Date | 2024-05-13 |