| NPI | 1417585654 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0007255) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OK 3174) |
| Enumeration Date | 2020-04-01 |
| Last Update Date | 2022-12-15 |