| NPI | 1033726526 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0006420) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WY PT936) |
| Enumeration Date | 2020-09-28 |
| Last Update Date | 2022-11-22 |