| NPI | 1447345624 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2003-0014) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| 208D00000X General Practice (Licence: NM PA2003-0014) | |
| Enumeration Date | 2006-10-04 |
| Last Update Date | 2010-08-06 |