| NPI | 1396148151 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO PA.0004736) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085-005266) |
| Enumeration Date | 2014-10-07 |
| Last Update Date | 2018-12-27 |