| NPI | 1366871972 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA. 0003986) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM PA2013-0074) |
| Enumeration Date | 2013-11-04 |
| Last Update Date | 2015-08-11 |