| NPI | 1720052640 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 163WP2201X Registered Nurse, Ambulatory Care (Licence: KS 13-116483-012) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: KS 24-00315) |
| Enumeration Date | 2006-02-15 |
| Last Update Date | 2015-01-03 |