| NPI | 1093226862 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 021346-1) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00452100) |
| Enumeration Date | 2017-10-19 |
| Last Update Date | 2022-07-21 |