| NPI | 1972516359 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2013-0057) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NM 237) |
| Enumeration Date | 2006-08-15 |
| Last Update Date | 2023-09-08 |