| NPI | 1073914966 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO PA.0007780) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AZ 5871) |
| Enumeration Date | 2014-09-10 |
| Last Update Date | 2023-12-05 |