| NPI | 1285368175 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA063789) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00794500) |
| Enumeration Date | 2022-07-15 |
| Last Update Date | 2025-07-22 |