| NPI | 1861938060 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2022-0077) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 007962) |
| Enumeration Date | 2017-01-11 |
| Last Update Date | 2024-08-12 |