| NPI | 1427408251 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110010591) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-1610) |
| 363A00000X Physician Assistant (Licence: CO 4759) | |
| Enumeration Date | 2016-06-13 |
| Last Update Date | 2025-03-31 |