| NPI | 1821355454 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0006653) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TN PA2126) |
| Enumeration Date | 2012-04-20 |
| Last Update Date | 2021-04-22 |