| NPI | 1861840993 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0005328) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA15667) |
| 363A00000X Physician Assistant (Licence: NV PA2614) | |
| 363A00000X Physician Assistant (Licence: ID PA-2189) | |
| Enumeration Date | 2016-05-31 |
| Last Update Date | 2022-04-28 |