| NPI | 1073289500 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MP 124) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CO PA.0006841) |
| Enumeration Date | 2021-08-16 |
| Last Update Date | 2024-03-13 |