| NPI | 1669756128 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 55067) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-03867) |
| 363A00000X Physician Assistant (Licence: CO 55067) | |
| Enumeration Date | 2011-10-03 |
| Last Update Date | 2017-12-08 |