| NPI | 1902230113 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO 0003775) |
| 363AM0700X Physician Assistant, Medical (Licence: CO PA.0003775) | |
| Enumeration Date | 2013-08-23 |
| Last Update Date | 2019-08-06 |