| NPI | 1710327366 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NM PA2013-0025) |
| Additional Taxonomies | 208100000X Physical Medicine & Rehabilitation (Licence: NM PA2013-0025) |
| Enumeration Date | 2013-06-27 |
| Last Update Date | 2023-11-08 |