| NPI | 1104259373 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NJ 25MP00315300) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 016691-1) |
| Enumeration Date | 2013-08-12 |
| Last Update Date | 2013-08-12 |