| NPI | 1689140881 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2020-0022) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CO PA.0006092) |
| Enumeration Date | 2018-10-16 |
| Last Update Date | 2020-03-19 |