| NPI | 1922475011 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO 5967) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 3950) |
| 363A00000X Physician Assistant (Licence: IA 079460) | |
| Enumeration Date | 2015-08-25 |
| Last Update Date | 2020-02-03 |