| NPI | 1356107601 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NJ 25MP00837000) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA065386) |
| Enumeration Date | 2024-02-26 |
| Last Update Date | 2024-12-31 |