| NPI | 1679510887 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0002045) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO 2045) |
| Enumeration Date | 2006-05-31 |
| Last Update Date | 2025-01-13 |