| NPI | 1619919503 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: SD 0874) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO 393) |
| Enumeration Date | 2006-06-12 |
| Last Update Date | 2014-03-11 |