| NPI | 1578964698 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NM PA2015-0086) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NC 0010-05227) |
| 363AM0700X Physician Assistant, Medical (Licence: TX PA11269) | |
| Enumeration Date | 2014-09-08 |
| Last Update Date | 2022-01-31 |