| NPI | 1942386776 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 164W00000X Licensed Practical Nurse (Licence: NV APRN001803) |
| Additional Taxonomies | 363LF0000X Nurse Practitioner, Family (Licence: IL 209-005046) |
| 363LF0000X Nurse Practitioner, Family (Licence: WI 2167-033) | |
| Enumeration Date | 2006-10-27 |
| Last Update Date | 2014-12-10 |