| NPI | 1720454796 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0004998) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AK 102828) |
| Enumeration Date | 2015-08-13 |
| Last Update Date | 2023-03-07 |