| NPI | 1255859526 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0005836) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2017-09-06 |
| Last Update Date | 2020-04-07 |