| NPI | 1154355774 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NJ 25MP00248400) |
| Additional Taxonomies | 225100000X Physical Therapist (Licence: NJ 40QA01027600) |
| 2251S0007X Physical Therapist, Sports (Licence: NJ 40QA01027600) | |
| 2251X0800X Physical Therapist, Orthopedic (Licence: NJ 40QA01027600) | |
| 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NJ 25MT00120500) | |
| 363AS0400X Physician Assistant, Surgical (Licence: PA MA054556) | |
| Enumeration Date | 2006-07-10 |
| Last Update Date | 2010-12-07 |