| NPI | 1902857725 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA-2763) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA01030) |
| Enumeration Date | 2006-05-15 |
| Last Update Date | 2017-04-04 |