| NPI | 1326406083 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO 0005837) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-09275) |
| 363AS0400X Physician Assistant, Surgical (Licence: CO 0005837) | |
| Enumeration Date | 2016-02-09 |
| Last Update Date | 2024-01-30 |