| NPI | 1770503153 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0004948) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA02748) |
| Enumeration Date | 2006-07-20 |
| Last Update Date | 2017-04-26 |