| NPI | 1003814849 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA-2940) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 05-25395) |
| 363A00000X Physician Assistant (Licence: MO 2004027792) | |
| Enumeration Date | 2005-07-13 |
| Last Update Date | 2011-06-06 |