| NPI | 1679800189 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9112668) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 1090608) |
| 363A00000X Physician Assistant (Licence: CO PA.0004626) | |
| 363AM0700X Physician Assistant, Medical (Licence: CO PA.0004626) | |
| Enumeration Date | 2009-11-05 |
| Last Update Date | 2024-04-01 |