| NPI | 1225275647 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA PA9508) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: MD C03597) |
| 363AM0700X Physician Assistant Medical (Licence: NJ 25MP00738600) | |
| Enumeration Date | 2009-01-08 |
| Last Update Date | 2023-07-17 |