| NPI | 1295457778 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0007544) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0012521) |
| Enumeration Date | 2022-09-13 |
| Last Update Date | 2026-08-06 |