| NPI | 1427619113 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0008754) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C07465) |
| Enumeration Date | 2019-06-24 |
| Last Update Date | 2024-10-15 |