| NPI | 1265822308 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0004976) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NC 0010-05501) |
| 363AS0400X Physician Assistant, Surgical (Licence: SC 2492) | |
| Enumeration Date | 2015-01-28 |
| Last Update Date | 2017-05-09 |