| NPI | 1992833420 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: TX AT3805) |
| Enumeration Date | 2007-02-28 |
| Last Update Date | 2011-11-07 |