| NPI | 1467972612 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NJ 25MP00577200) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: SC 3083) |
| 363AS0400X Physician Assistant, Surgical (Licence: NJ 25MP00577200) | |
| 363AS0400X Physician Assistant, Surgical (Licence: CA PA54487) | |
| 363AM0700X Physician Assistant, Medical (Licence: CA PA54487) | |
| Enumeration Date | 2017-06-20 |
| Last Update Date | 2025-01-03 |