| NPI | 1174156699 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0008149) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WY PA1252) |
| Enumeration Date | 2020-02-13 |
| Last Update Date | 2025-10-22 |