| NPI | 1982790150 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: CO CO 1391) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KS 15-02426) |
| Enumeration Date | 2006-10-05 |
| Last Update Date | 2021-08-18 |