| NPI | 1710458179 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0006080) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO 0006080) |
| 363A00000X Physician Assistant (Licence: CO PA.0006080) | |
| Enumeration Date | 2018-12-11 |
| Last Update Date | 2022-05-10 |