| NPI | 1568947000 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA14498) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA.0005546) |
| Enumeration Date | 2018-10-01 |
| Last Update Date | 2021-08-04 |