| NPI | 1558883074 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO PA.0006338) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DC PA031373) |
| 363AS0400X Physician Assistant, Surgical (Licence: CO PA0006338) | |
| Enumeration Date | 2017-07-17 |
| Last Update Date | 2025-06-16 |