| NPI | 1265065718 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO PA.0008015) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA59963) |
| Enumeration Date | 2020-02-12 |
| Last Update Date | 2025-01-14 |