| NPI | 1154442390 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-00859) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 144700) |
| Enumeration Date | 2007-04-03 |
| Last Update Date | 2012-10-15 |