| NPI | 1912608514 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0008700) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 363AM0700X Physician Assistant, Medical | |
| 363AM0700X Physician Assistant, Medical (Licence: CO PA.0008700) | |
| 363AS0400X Physician Assistant, Surgical | |
| 363AS0400X Physician Assistant, Surgical (Licence: CO PA.0008700) | |
| Enumeration Date | 2023-03-13 |
| Last Update Date | 2024-12-19 |