| NPI | 1255928008 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NJ 25MP00603700) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 026131) |
| Enumeration Date | 2020-12-28 |
| Last Update Date | 2024-08-01 |