| NPI | 1417592890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO PA.0006967) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA13211) |
| Enumeration Date | 2019-11-09 |
| Last Update Date | 2021-10-13 |