| NPI | 1770596777 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2016-0078) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OK PA-598) |
| Enumeration Date | 2006-08-14 |
| Last Update Date | 2018-06-11 |