NPI | 1184629602 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | No |
Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO PA.0000903) |
Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA472) |
Enumeration Date | 2005-06-21 |
Last Update Date | 2018-11-20 |