| NPI | 1164156857 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA064767) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00713600) |
| Enumeration Date | 2022-07-11 |
| Last Update Date | 2024-02-22 |