| NPI | 1205294345 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0005667) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NE 1995) |
| Enumeration Date | 2016-02-03 |
| Last Update Date | 2020-11-20 |