| NPI | 1205259447 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110008156) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA0003903) |
| 363AM0700X Physician Assistant, Medical (Licence: CO PA.0003903) | |
| Enumeration Date | 2014-01-23 |
| Last Update Date | 2021-12-18 |