| NPI | 1619091451 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0002245) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 20331) |
| 363AM0700X Physician Assistant, Medical (Licence: AK 506) | |
| 363AM0700X Physician Assistant, Medical (Licence: WY 195) | |
| 363AM0700X Physician Assistant, Medical (Licence: CO 2245) | |
| Enumeration Date | 2007-03-19 |
| Last Update Date | 2020-02-19 |