| NPI | 1265816813 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 164W00000X Licensed Practical Nurse (Licence: AK 102539) |
| Additional Taxonomies | 164X00000X Licensed Vocational Nurse (Licence: TX 221291) |
| Enumeration Date | 2015-07-14 |
| Last Update Date | 2016-10-19 |