| NPI | 1548877400 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA0008866) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085.007894) |
| Enumeration Date | 2020-09-25 |
| Last Update Date | 2024-11-20 |