| NPI | 1093202863 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 164W00000X Licensed Practical Nurse (Licence: TX 325857) |
| Additional Taxonomies | 164W00000X Licensed Practical Nurse (Licence: WA LP60845138) |
| Enumeration Date | 2018-04-17 |
| Last Update Date | 2018-04-17 |