| NPI | 1225210693 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2006-0014) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA PA13273) |
| Enumeration Date | 2007-11-28 |
| Last Update Date | 2008-06-17 |