| NPI | 1679071526 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0006240) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: MN 12987) |
| Enumeration Date | 2018-01-25 |
| Last Update Date | 2021-04-12 |