| NPI | 1538625595 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CT 5205) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA.0005713) |
| Enumeration Date | 2019-02-14 |
| Last Update Date | 2023-01-04 |