| NPI | 1275776700 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PTL.0003390) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 20209) |
| 363AS0400X Physician Assistant, Surgical (Licence: CO 3390) | |
| Enumeration Date | 2009-04-14 |
| Last Update Date | 2025-11-20 |