| NPI | 1316970163 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO PA.0002579) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MO 2003002307) |
| Enumeration Date | 2006-07-07 |
| Last Update Date | 2023-07-12 |