| NPI | 1588116586 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT 57614) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM PA2016-0086) |
| Enumeration Date | 2016-10-26 |
| Last Update Date | 2023-11-27 |