| NPI | 1457918450 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MO 2020042060) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00522100) |
| Enumeration Date | 2019-05-24 |
| Last Update Date | 2021-09-20 |