| NPI | 1194202879 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-13140) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA.0005423) |
| Enumeration Date | 2018-07-25 |
| Last Update Date | 2023-04-17 |