| NPI | 1073063772 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2018-0087) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OR PA180086) |
| Enumeration Date | 2016-10-06 |
| Last Update Date | 2023-12-06 |