| NPI | 1679571475 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0003377) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MI 5601002360) |
| Enumeration Date | 2005-07-14 |
| Last Update Date | 2023-03-07 |