| NPI | 1982093126 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO 0005696) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-05474) |
| Enumeration Date | 2015-01-12 |
| Last Update Date | 2019-03-25 |