| NPI | 1205903945 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2013-0040) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: AL PA403) |
| Enumeration Date | 2006-11-29 |
| Last Update Date | 2022-01-10 |