| NPI | 1245498971 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA0005173) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 002714) |
| Enumeration Date | 2008-05-29 |
| Last Update Date | 2019-01-23 |