| NPI | 1689918278 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-08128) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO 3555) |
| Enumeration Date | 2012-11-20 |
| Last Update Date | 2023-10-24 |