| NPI | 1043490121 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO 0003181) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IA 001867) |
| Enumeration Date | 2007-11-06 |
| Last Update Date | 2025-01-15 |