| NPI | 1154937001 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0009381) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NE 2477) |
| 363AS0400X Physician Assistant, Surgical (Licence: WY PT1013) | |
| 363A00000X Physician Assistant (Licence: IA 105753) | |
| Enumeration Date | 2020-09-16 |
| Last Update Date | 2025-12-03 |