| NPI | 1013507730 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA.0006651) |
| Enumeration Date | 2021-01-26 |
| Last Update Date | 2023-09-08 |