| NPI | 1619515764 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2020-0023) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NM PA2020-0023) |
| 363A00000X Physician Assistant | |
| Enumeration Date | 2019-12-18 |
| Last Update Date | 2021-08-05 |