| NPI | 1154801041 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 164W00000X Licensed Practical Nurse (Licence: KY 2046317) |
| Additional Taxonomies | 164W00000X Licensed Practical Nurse (Licence: FL PN5205723) |
| Enumeration Date | 2018-08-20 |
| Last Update Date | 2018-08-20 |