| NPI | 1730765637 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA219016) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA.0006652) |
| Enumeration Date | 2021-03-22 |
| Last Update Date | 2024-04-19 |