| NPI | 1972593515 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MO TR00196) |
| Enumeration Date | 2005-10-25 |
| Last Update Date | 2007-07-08 |