| NPI | 1184275612 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 164W00000X Licensed Practical Nurse (Licence: IL 043.126744) |
| Additional Taxonomies | 164W00000X Licensed Practical Nurse (Licence: SC 48498) |
| Enumeration Date | 2019-09-25 |
| Last Update Date | 2019-09-25 |