| NPI | 1225479975 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 016612) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00400400) |
| Enumeration Date | 2013-07-10 |
| Last Update Date | 2021-06-17 |