| NPI | 1649235581 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: ID PA-1602) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO 757) |
| Enumeration Date | 2006-04-20 |
| Last Update Date | 2018-05-22 |