| NPI | 1144787805 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: UT 11820832-1206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA.0006153) |
| 363AS0400X Physician Assistant, Surgical (Licence: UT 11820832-1206) | |
| Enumeration Date | 2019-02-28 |
| Last Update Date | 2022-06-10 |