| NPI | 1326397829 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2012-0053) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2012-08-30 |
| Last Update Date | 2017-01-20 |