| NPI | 1093130783 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NM PA2014-0082) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: AZ 5647) |
| 363AS0400X Physician Assistant, Surgical (Licence: AZ 5647) | |
| Enumeration Date | 2014-03-04 |
| Last Update Date | 2017-05-11 |