| NPI | 1285614735 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO co1679) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MN 11924) |
| Enumeration Date | 2006-01-19 |
| Last Update Date | 2019-11-11 |