| NPI | 1114007028 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: WY 208) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WY PA208) |
| 363AS0400X Physician Assistant Surgical (Licence: CO PA-2238) | |
| Enumeration Date | 2006-10-16 |
| Last Update Date | 2022-11-07 |