| NPI | 1265769962 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9113427) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 015389) |
| 363A00000X Physician Assistant (Licence: NJ 25MP00228500) | |
| Enumeration Date | 2009-11-17 |
| Last Update Date | 2022-08-31 |