| NPI | 1154646248 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NM PA2014-14) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2010-03-31 |
| Last Update Date | 2022-09-16 |