| NPI | 1912459637 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO PA.0005779) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: DE C5-0001095) |
| Enumeration Date | 2016-10-28 |
| Last Update Date | 2021-11-22 |