| NPI | 1881367530 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2021-0075) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2021-07-28 |
| Last Update Date | 2024-11-14 |