| NPI | 1346352069 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NJ 25MP00340600) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 96002342) |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2006-08-31 |
| Last Update Date | 2022-07-26 |