| NPI | 1316107493 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO 2490) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CO 1079274) |
| 363AS0400X Physician Assistant, Surgical (Licence: CO 2490) | |
| Enumeration Date | 2008-06-12 |
| Last Update Date | 2021-05-15 |