| NPI | 1992030803 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: ID AT468) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: MI 2601001331) |
| 2255A2300X Specialist/Technologist Athletic Trainer (Licence: FL AL 2738) | |
| 2255A2300X Specialist/Technologist Athletic Trainer (Licence: OR 10160747) | |
| 246Z00000X Specialist/Technologist, Other (Licence: ID #13-0839) | |
| Enumeration Date | 2009-10-09 |
| Last Update Date | 2020-03-19 |