| NPI | 1225121064 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD 0003460) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP000308) |
| Enumeration Date | 2006-10-02 |
| Last Update Date | 2007-07-20 |