| NPI | 1588628192 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NM PA2017-0049) |
| 363AS0400X Physician Assistant, Surgical (Licence: CO PA2150) | |
| Enumeration Date | 2006-04-12 |
| Last Update Date | 2023-06-15 |