| NPI | 1689228397 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0007251) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 026088) |
| Enumeration Date | 2019-07-31 |
| Last Update Date | 2025-07-24 |