| NPI | 1073863213 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO PA.0004176) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA055722) |
| Enumeration Date | 2012-09-14 |
| Last Update Date | 2025-04-07 |