| NPI | 1407378136 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO PA0007294) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA60779457) |
| Enumeration Date | 2017-07-14 |
| Last Update Date | 2025-06-23 |