| NPI | 1184143125 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: IA 110766) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA.0005141) |
| 363A00000X Physician Assistant (Licence: NE 2181) | |
| 363AM0700X Physician Assistant Medical (Licence: CO PA.0005141) | |
| Enumeration Date | 2017-09-11 |
| Last Update Date | 2023-01-25 |