| NPI | 1104071117 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 163W00000X Registered Nurse (Licence: MO 148495) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: KS 14-80206-071) |
| Enumeration Date | 2008-11-19 |
| Last Update Date | 2008-11-19 |