| NPI | 1174742944 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9107209) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 0064591) |
| 363A00000X Physician Assistant (Licence: CO PA-3186) | |
| Enumeration Date | 2007-04-24 |
| Last Update Date | 2019-05-20 |