| NPI | 1609120617 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO 5161) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA056314) |
| Enumeration Date | 2012-10-30 |
| Last Update Date | 2019-12-27 |