| NPI | 1396779096 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO 2229) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TX PA04370) |
| Enumeration Date | 2006-07-10 |
| Last Update Date | 2013-08-14 |