| NPI | 1023379021 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NJ 25mp00276100) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 015386) |
| Enumeration Date | 2012-06-06 |
| Last Update Date | 2012-06-06 |