| NPI | 1144652108 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NM PA2013-0044) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NM PA2013-0044) |
| Enumeration Date | 2013-08-01 |
| Last Update Date | 2024-09-13 |