| NPI | 1215937354 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NJ 25MP00701300) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: KY PA581) |
| Enumeration Date | 2005-07-29 |
| Last Update Date | 2023-03-10 |