| NPI | 1922147610 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 164W00000X Licensed Practical Nurse (Licence: CO 44156)  | 
| Additional Taxonomies | 164W00000X Licensed Practical Nurse (Licence: NE 20219)  | 
| Enumeration Date | 2007-02-06 | 
| Last Update Date | 2007-07-08 |