| NPI | 1992184360 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: WA A1 60543430) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: ID AT-502) |
| Enumeration Date | 2015-05-19 |
| Last Update Date | 2015-05-19 |