| NPI | 1144773524 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0005780) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CT 3715) |
| Enumeration Date | 2016-08-02 |
| Last Update Date | 2021-10-14 |