| NPI | 1992988240 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MT MT-605) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NM PA2017-0059) |
| Enumeration Date | 2007-12-10 |
| Last Update Date | 2025-03-08 |