| NPI | 1720154669 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA0001079) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO 1079) |
| Enumeration Date | 2006-11-24 |
| Last Update Date | 2013-11-27 |