| NPI | 1801177464 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0006558) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085-005798) |
| 363A00000X Physician Assistant (Licence: SC 2318) | |
| 363A00000X Physician Assistant (Licence: NY 014868) | |
| Enumeration Date | 2011-09-08 |
| Last Update Date | 2021-05-17 |