| NPI | 1124135264 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO 738) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 10057) |
| Enumeration Date | 2006-08-24 |
| Last Update Date | 2008-01-15 |