| NPI | 1104885615 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 2084P0301X Psychiatry & Neurology, Brain Injury Medicine (Licence: CO PA2353) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA12294) |
| 363AM0700X Physician Assistant, Medical (Licence: CO 2353) | |
| Enumeration Date | 2006-03-22 |
| Last Update Date | 2023-11-13 |