| NPI | 1790945988 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA 2003-0032) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NM 2003-0032) |
| Enumeration Date | 2008-06-11 |
| Last Update Date | 2014-09-09 |