| NPI | 1386894525 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2008-0047) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: CA PA20978) |
| Enumeration Date | 2008-09-24 |
| Last Update Date | 2011-08-04 |