| NPI | 1912158056 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 172V00000X Community Health Worker (Licence: WI 4596-027) |
| Additional Taxonomies | 172V00000X Community Health Worker (Licence: MN 201458) |
| Enumeration Date | 2008-10-07 |
| Last Update Date | 2011-11-25 |