| NPI | 1255627501 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 193400000X Single Specialty (Licence: NJ 25MA09903400) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY 000000000000) |
| Enumeration Date | 2011-06-24 |
| Last Update Date | 2018-11-02 |