NPI | 1104835594 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO 3167) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: IN 10000879A) |
363A00000X Physician Assistant | |
Enumeration Date | 2006-08-05 |
Last Update Date | 2021-10-20 |