| NPI | 1982024345 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2014000963) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 096003682) |
| Enumeration Date | 2014-04-23 |
| Last Update Date | 2014-04-23 |