| NPI | 1124364211 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NJ 25MP00644100) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 015934) |
| 363A00000X Physician Assistant (Licence: CA 22630) | |
| Enumeration Date | 2012-12-18 |
| Last Update Date | 2021-11-11 |