| NPI | 1972189009 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM PA2020-0116) |
| Enumeration Date | 2021-03-19 |
| Last Update Date | 2021-06-08 |