| NPI | 1053772392 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AK 219361) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CO PA0004580) |
| Enumeration Date | 2016-03-15 |
| Last Update Date | 2024-11-12 |