| NPI | 1184895948 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2016-0027) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-01302) |
| Enumeration Date | 2008-03-19 |
| Last Update Date | 2021-02-18 |