| NPI | 1871597856 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2017-0005) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OK 1352) |
| Enumeration Date | 2005-06-08 |
| Last Update Date | 2017-03-28 |