| NPI | 1760404693 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: CO PA0003466) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: AZ 3279) |
| Enumeration Date | 2006-07-23 |
| Last Update Date | 2014-04-22 |