| NPI | 1134184336 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2019-0056) |
| Additional Taxonomies | 1710I1002X Military Health Care Provider, Independent Duty Corpsman |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2006-04-19 |
| Last Update Date | 2019-08-02 |