| NPI | 1053067140 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NJ 25MP00740700) |
| Additional Taxonomies | 363A00000X Physician Assistant |
| Enumeration Date | 2022-02-27 |
| Last Update Date | 2025-10-23 |