| NPI | 1306556519 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NJ 25MP00772600) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085010201) |
| Enumeration Date | 2022-11-29 |
| Last Update Date | 2025-09-24 |