| NPI | 1013622752 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2023-0040) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2023-01-17 |
| Last Update Date | 2023-05-17 |