| NPI | 1780383505 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0009248) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2023-03-01 |
| Last Update Date | 2025-08-05 |