| NPI | 1417126145 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0002778) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA05601) |
| Enumeration Date | 2008-02-27 |
| Last Update Date | 2022-10-11 |