| NPI | 1225326978 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0005518) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 2794) |
| Enumeration Date | 2011-07-15 |
| Last Update Date | 2018-10-23 |