| NPI | 1972805687 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 164W00000X Licensed Practical Nurse (Licence: MI 4703119527) |
| Additional Taxonomies | 164W00000X Licensed Practical Nurse (Licence: NY 301917) |
| Enumeration Date | 2010-12-01 |
| Last Update Date | 2018-03-17 |