| NPI | 1063415156 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: AK 135562) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM PA2004-0044) |
| 363AM0700X Physician Assistant Medical (Licence: CO 2300) | |
| Enumeration Date | 2005-05-23 |
| Last Update Date | 2021-08-09 |