| NPI | 1881790939 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: CO 2657) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NM PA2005-0012) |
| Enumeration Date | 2006-09-16 |
| Last Update Date | 2024-11-18 |