| NPI | 1659591279 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NM PA2010-0054) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CA 18180) |
| Enumeration Date | 2007-04-26 |
| Last Update Date | 2017-03-22 |