| NPI | 1265946222 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9113658) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00456500) |
| Enumeration Date | 2017-11-28 |
| Last Update Date | 2021-07-27 |