| NPI | 1164021713 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NJ 25MP00676700) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA061958) |
| Enumeration Date | 2020-10-23 |
| Last Update Date | 2022-03-31 |