| NPI | 1891773818 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NM 84-PA002) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM 91-165) |
| Enumeration Date | 2006-01-09 |
| Last Update Date | 2013-07-15 |