| NPI | 1053314310 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO 2432) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 2588) |
| Enumeration Date | 2005-05-31 |
| Last Update Date | 2014-12-22 |