| NPI | 1417097155 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 60461) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CO 3273) |
| 363AM0700X Physician Assistant, Medical (Licence: MO 2007002728) | |
| Enumeration Date | 2007-02-08 |
| Last Update Date | 2022-04-13 |