| NPI | 1811966385 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO PA.0001279) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: KS 15-00965) |
| 363AM0700X Physician Assistant, Medical (Licence: NM PA2010-0073) | |
| Enumeration Date | 2006-03-16 |
| Last Update Date | 2014-04-24 |