| NPI | 1780865824 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA0004283) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MA AP2447) |
| Enumeration Date | 2007-11-16 |
| Last Update Date | 2022-07-21 |