| NPI | 1033153275 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0005934) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: FL XXXXXXXXXXXXXX) |
| Enumeration Date | 2006-06-16 |
| Last Update Date | 2020-01-14 |