| NPI | 1134863921 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 164W00000X Licensed Practical Nurse (Licence: FL 11037116) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PR 1239) |
| Enumeration Date | 2022-04-26 |
| Last Update Date | 2025-01-14 |