| NPI | 1265626840 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0004892) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 15--01235) |
| Enumeration Date | 2007-08-28 |
| Last Update Date | 2017-02-16 |