| NPI | 1407845845 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA056681) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9103071) |
| 363A00000X Physician Assistant (Licence: NJ 25MP00486300) | |
| Enumeration Date | 2005-10-18 |
| Last Update Date | 2025-11-19 |