| NPI | 1508883166 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0004233) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 1071717) |
| Enumeration Date | 2006-07-17 |
| Last Update Date | 2020-02-19 |