| NPI | 1548627284 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2021-0018) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: SD 1024) |
| 363A00000X Physician Assistant | |
| 363A00000X Physician Assistant (Licence: TN 3070) | |
| Enumeration Date | 2016-01-26 |
| Last Update Date | 2021-03-11 |