| NPI | 1659714590 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO PA.0005916) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: IL 085-004681) |
| Enumeration Date | 2013-04-10 |
| Last Update Date | 2019-10-30 |