| NPI | 1659723120 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR 185403) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA.0004668) |
| Enumeration Date | 2016-07-08 |
| Last Update Date | 2018-02-06 |