| NPI | 1659612083 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 164W00000X Licensed Practical Nurse (Licence: IL 043116557) |
| Additional Taxonomies | 164W00000X Licensed Practical Nurse (Licence: WI 316422-31) |
| Enumeration Date | 2013-03-11 |
| Last Update Date | 2013-03-11 |