| NPI | 1972784502 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CO PA.0002506) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO 2506) |
| Enumeration Date | 2007-11-26 |
| Last Update Date | 2020-06-01 |