| NPI | 1700065422 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 9308) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM PA2009-0013) |
| 363AM0700X Physician Assistant, Medical (Licence: NM PA2009-0013) | |
| Enumeration Date | 2007-10-30 |
| Last Update Date | 2019-08-30 |