| NPI | 1790294759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0005165) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2017-09-21 |
| Last Update Date | 2017-10-03 |