| NPI | 1558883074 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CO PA0006338) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DC PA031373) |
| Enumeration Date | 2017-07-17 |
| Last Update Date | 2020-10-28 |