| NPI | 1528795622 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM PA2024-0083) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-08-08 |
| Last Update Date | 2024-08-21 |