| NPI | 1053997064 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA063522) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00646800) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2021-03-20 |
| Last Update Date | 2025-01-28 |