| NPI | 1396381315 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: MD CO7357) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA061197) |
| Enumeration Date | 2019-11-25 |
| Last Update Date | 2023-08-29 |