| NPI | 1992801179 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: CO PA.0008209) | 
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: TX PA01678) | 
| Enumeration Date | 2006-09-15 | 
| Last Update Date | 2025-03-04 |