| NPI | 1861508590 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0007240) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-11259) |
| 363A00000X Physician Assistant (Licence: CA PA16602) | |
| Enumeration Date | 2006-08-23 |
| Last Update Date | 2023-10-27 |