| NPI | 1639128192 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO 2990) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA CA13524) |
| Enumeration Date | 2006-05-10 |
| Last Update Date | 2011-02-25 |