| NPI | 1467685909 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: VA 0110003029) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO 3340) |
| 363AM0700X Physician Assistant, Medical | |
| Enumeration Date | 2009-09-01 |
| Last Update Date | 2020-10-26 |