| NPI | 1962104836 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C08882) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA.0009426) |
| Enumeration Date | 2023-03-21 |
| Last Update Date | 2026-09-04 |