| NPI | 1104281062 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NJ 25MP00454400) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA059225) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-12-20 |
| Last Update Date | 2022-03-01 |