| NPI | 1396017828 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 001006871) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO 1103276) |
| Enumeration Date | 2012-01-30 |
| Last Update Date | 2019-11-27 |