| NPI | 1952787764 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: CO PA.0004875) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: SC 2396) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2015-08-04 |
| Last Update Date | 2024-03-20 |