| NPI | 1811360670 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0006149) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: ID PA-1406) |
| Enumeration Date | 2015-11-02 |
| Last Update Date | 2024-11-12 |