| NPI | 1477883486 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2024-0084) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C0004092) |
| 363AS0400X Physician Assistant, Surgical (Licence: MD CO4092) | |
| Enumeration Date | 2010-01-14 |
| Last Update Date | 2024-10-11 |