| NPI | 1053399451 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO 2850) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: VA 0110002173) |
| Enumeration Date | 2006-01-05 |
| Last Update Date | 2020-05-12 |