| NPI | 1407504731 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2022-0133) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NM PA2022-0133) |
| Enumeration Date | 2022-03-15 |
| Last Update Date | 2023-04-26 |