| NPI | 1205551132 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: DE C5-0011817) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NJ 25MP00955100) |
| Enumeration Date | 2022-10-04 |
| Last Update Date | 2025-09-06 |