| NPI | 1972683084 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0003692) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: VA 0110003772) |
| Enumeration Date | 2006-10-16 |
| Last Update Date | 2020-05-26 |