| NPI | 1205273844 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2013-0026) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NM PA2013-0026) |
| 363AM0700X Physician Assistant, Medical (Licence: NM PA2013-0026) | |
| Enumeration Date | 2013-05-22 |
| Last Update Date | 2024-01-15 |