| NPI | 1164779955 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0004684) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00266100) |
| 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0004684) | |
| Enumeration Date | 2012-08-10 |
| Last Update Date | 2017-11-09 |