| NPI | 1154742658 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 017270) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00671700) |
| Enumeration Date | 2013-12-30 |
| Last Update Date | 2024-12-09 |