| NPI | 1205372547 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0008934) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 1502640) |
| Enumeration Date | 2017-01-10 |
| Last Update Date | 2025-01-16 |