| NPI | 1245332501 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM2500X Clinic/Center, Medical Specialty |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CO 1302) |
| Enumeration Date | 2006-09-05 |
| Last Update Date | 2007-07-08 |