| NPI | 1386156891 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA059239) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CO PA.0006034) |
| Enumeration Date | 2017-10-25 |
| Last Update Date | 2021-11-05 |