| NPI | 1205412665 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0008412) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MN 13665) |
| Enumeration Date | 2021-03-24 |
| Last Update Date | 2026-01-28 |