| NPI | 1841220043 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 2780) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM PA2019-0008) |
| Enumeration Date | 2006-07-03 |
| Last Update Date | 2026-06-01 |