| NPI | 1770990848 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 7242) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM PA2016-0024) |
| Enumeration Date | 2014-07-21 |
| Last Update Date | 2024-11-12 |