| NPI | 1740665744 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0005655) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9108791) |
| 363A00000X Physician Assistant (Licence: CO PA0005655) | |
| Enumeration Date | 2015-07-21 |
| Last Update Date | 2024-05-22 |