| NPI | 1487888061 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: GA 006400) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 6400) |
| 363AS0400X Physician Assistant, Surgical (Licence: NJ 25MP00214500) | |
| Enumeration Date | 2009-05-11 |
| Last Update Date | 2022-01-10 |