| NPI | 1699802926 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2020-0008) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NV 421) |
| Enumeration Date | 2007-02-27 |
| Last Update Date | 2020-03-04 |