| NPI | 1982715397 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO 2701) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NE 645) |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2021-09-16 |