| NPI | 1134225592 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO 2460) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WV 00380) |
| Enumeration Date | 2006-09-15 |
| Last Update Date | 2013-08-14 |