| NPI | 1669937199 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO PA.0005651) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NV PA2097) |
| Enumeration Date | 2019-02-08 |
| Last Update Date | 2024-01-16 |