| NPI | 1992034631 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: MO 2007008863) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TX AT6621) |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: SD 0328) | |
| Enumeration Date | 2009-12-09 |
| Last Update Date | 2021-01-28 |