| NPI | 1033197538 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: NM PA2013-0094) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: TX PA01205) |
| Enumeration Date | 2006-01-04 |
| Last Update Date | 2014-05-15 |