| NPI | 1053631200 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0003881) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2010-06-09 |
| Last Update Date | 2018-10-22 |