| NPI | 1912914854 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO PA 2281) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA05781) |
| Enumeration Date | 2006-08-02 |
| Last Update Date | 2013-08-14 |