| NPI | 1982646956 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2023-0009) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9103929) |
| Enumeration Date | 2006-06-12 |
| Last Update Date | 2023-08-21 |