| NPI | 1780015727 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO PA.0004460) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SD 0881) |
| 363A00000X Physician Assistant (Licence: IL 085.004947) | |
| 363A00000X Physician Assistant (Licence: CO PA.0004460) | |
| Enumeration Date | 2013-12-02 |
| Last Update Date | 2018-10-16 |