| NPI | 1912331869 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0004191) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA056325) |
| Enumeration Date | 2013-08-28 |
| Last Update Date | 2019-12-19 |