| NPI | 1780690438 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM 94-PA37) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NH 0994) |
| Enumeration Date | 2006-08-01 |
| Last Update Date | 2025-01-09 |