| NPI | 1326355702 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NJ 25MP00242500) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NJ 25MP00242500) |
| 363AS0400X Physician Assistant Surgical (Licence: NJ 25MP00242500) | |
| Enumeration Date | 2010-09-08 |
| Last Update Date | 2010-09-08 |