| NPI | 1982973087 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: ME AT984) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: KY AT2282) | |
| Enumeration Date | 2011-12-19 |
| Last Update Date | 2025-12-02 |