| NPI | 1154652378 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0005561) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 7570837-1206) |
| 363AM0700X Physician Assistant, Medical (Licence: CO PA.0005561) | |
| Enumeration Date | 2010-01-28 |
| Last Update Date | 2022-08-31 |