| NPI | 1760784219 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 163W00000X Registered Nurse (Licence: IL 041387765) |
| Additional Taxonomies | 164W00000X Licensed Practical Nurse (Licence: GA LPN078306) |
| 164W00000X Licensed Practical Nurse (Licence: IL 043100800) | |
| Enumeration Date | 2010-12-02 |
| Last Update Date | 2010-12-02 |