| NPI | 1831290790 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NM PA2006-0022) |
| Enumeration Date | 2006-09-25 |
| Last Update Date | 2022-06-24 |