| NPI | 1982050019 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: CT 001036) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: PA RTO000238) |
| Enumeration Date | 2016-05-07 |
| Last Update Date | 2016-05-07 |