| NPI | 1134665649 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NJ 25MP00556200) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085-006130) |
| 363AM0700X Physician Assistant, Medical (Licence: PA MA059711) | |
| Enumeration Date | 2017-01-09 |
| Last Update Date | 2024-08-08 |