| NPI | 1568913911 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 202K00000X (Licence: NM PA2016-0096) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NM PA20160096) |
| Enumeration Date | 2016-10-20 |
| Last Update Date | 2022-07-28 |