| NPI | 1851373526 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0003166) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA961) |
| Enumeration Date | 2005-11-17 |
| Last Update Date | 2026-02-09 |