| NPI | 1770968141 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 164W00000X Licensed Practical Nurse (Licence: SC PR47076) |
| Additional Taxonomies | 164W00000X Licensed Practical Nurse (Licence: GA LPN049887) |
| Enumeration Date | 2015-07-27 |
| Last Update Date | 2015-07-27 |