| NPI | 1689140881 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 10463) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM PA2020-0022) |
| Enumeration Date | 2018-10-16 |
| Last Update Date | 2025-01-14 |