| NPI | 1144870163 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 207QA0505X Family Medicine, Adult Medicine (Licence: AZ 7666) |
| 363AM0700X Physician Assistant, Medical (Licence: CO PA.0008239) | |
| Enumeration Date | 2019-09-12 |
| Last Update Date | 2024-02-27 |