| NPI | 1194560649 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 031935) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00858600) |
| Enumeration Date | 2024-06-26 |
| Last Update Date | 2024-06-30 |