| NPI | 1336519297 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NJ 25MP00467400) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA057831) |
| Enumeration Date | 2015-10-04 |
| Last Update Date | 2022-07-21 |