| NPI | 1558031864 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0007717) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: IN 10003309A) |
| 363A00000X Physician Assistant (Licence: CO PA.0007717) | |
| Enumeration Date | 2021-09-17 |
| Last Update Date | 2025-04-03 |