| NPI | 1124783584 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2021-0097) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: AL PA.1801) |
| Enumeration Date | 2021-11-01 |
| Last Update Date | 2023-07-21 |