| NPI | 1255689477 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO PA.0006146) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085.004331) |
| Enumeration Date | 2012-08-20 |
| Last Update Date | 2020-07-20 |