| NPI | 1699252189 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO 0005455) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0005455) |
| Enumeration Date | 2018-07-26 |
| Last Update Date | 2023-02-14 |