| NPI | 1386142313 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO mk4712750) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2018-01-24 |
| Last Update Date | 2019-02-04 |