| NPI | 1972880672 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WV AT001921) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: VA 0126000038) |
| Enumeration Date | 2011-11-08 |
| Last Update Date | 2025-05-19 |