| NPI | 1477977312 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-06633) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA0003868) |
| Enumeration Date | 2014-02-12 |
| Last Update Date | 2020-01-13 |