| NPI | 1679839930 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0003687) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA.0003687) |
| 363A00000X Physician Assistant (Licence: GA 6408) | |
| Enumeration Date | 2012-04-11 |
| Last Update Date | 2023-08-09 |