| NPI | 1225401730 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00382200) |
| 363AS0400X Physician Assistant Surgical (Licence: NJ 25MP00382200) | |
| Enumeration Date | 2015-11-05 |
| Last Update Date | 2023-01-06 |