| NPI | 1801371414 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0007468) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: TX PA12793) |
| 363AM0700X Physician Assistant, Medical (Licence: CO PA.0007468) | |
| Enumeration Date | 2018-09-28 |
| Last Update Date | 2023-08-07 |