| NPI | 1477120160 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2021-0053) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-11317) |
| Enumeration Date | 2021-06-10 |
| Last Update Date | 2022-06-04 |