| NPI | 1750306007 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0004596) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110002096) |
| 363A00000X Physician Assistant (Licence: NE 1030) | |
| Enumeration Date | 2006-07-13 |
| Last Update Date | 2022-12-23 |