| NPI | 1013253566 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0007914) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-04006) |
| Enumeration Date | 2013-01-02 |
| Last Update Date | 2023-10-16 |