| NPI | 1245512391 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO 3295) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA181757) |
| Enumeration Date | 2011-09-14 |
| Last Update Date | 2019-06-28 |