| NPI | 1922066455 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NM PA2011-0036) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: UT 53426961206) |
| Enumeration Date | 2006-05-03 |
| Last Update Date | 2020-07-14 |