| NPI | 1063123313 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.9800) |
| Additional Taxonomies | 246Z00000X Specialist/Technologist, Other |
| Enumeration Date | 2022-12-07 |
| Last Update Date | 2026-06-01 |