| NPI | 1043658347 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: CA 51936) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NM PA2013-0033) |
| Enumeration Date | 2013-06-08 |
| Last Update Date | 2015-05-18 |