| NPI | 1669013389 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0006701) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WA PA61174793) |
| 363AM0700X Physician Assistant Medical (Licence: OH 50.006068RX) | |
| 363AS0400X Physician Assistant Surgical (Licence: WA PA61174793) | |
| Enumeration Date | 2019-10-03 |
| Last Update Date | 2023-01-24 |