| NPI | 1770556581 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO 2067) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: WA PA10004697) |
| Enumeration Date | 2006-02-10 |
| Last Update Date | 2021-06-23 |