| NPI | 1457915977 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0007829) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA60956849) |
| Enumeration Date | 2019-04-30 |
| Last Update Date | 2024-06-21 |