| NPI | 1376707950 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9108694) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 012573) |
| 363A00000X Physician Assistant (Licence: NJ 25MP00197500) | |
| Enumeration Date | 2008-07-14 |
| Last Update Date | 2015-11-30 |