| NPI | 1619159456 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0005340) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 1080515) |
| Enumeration Date | 2007-12-04 |
| Last Update Date | 2018-04-18 |