| NPI | 1205968856 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2006-0019) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NM PA-2006-0019) |
| Enumeration Date | 2007-03-09 |
| Last Update Date | 2021-07-20 |