| NPI | 1013648880 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 028306-01) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00705500) |
| Enumeration Date | 2022-06-22 |
| Last Update Date | 2024-02-01 |