| NPI | 1023397940 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: OR PA168445) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00259300) |
| Enumeration Date | 2011-08-09 |
| Last Update Date | 2016-11-21 |