| NPI | 1770857302 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 164W00000X Licensed Practical Nurse (Licence: DE L2-0011175) |
| Additional Taxonomies | 164W00000X Licensed Practical Nurse (Licence: PA PN286937) |
| Enumeration Date | 2012-02-29 |
| Last Update Date | 2012-02-29 |