| NPI | 1013540566 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NJ 25MP00918200) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 5124-23) |
| Enumeration Date | 2020-02-12 |
| Last Update Date | 2025-06-04 |