| NPI | 1508117953 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NJ 25MP00298200) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA055669) |
| 363AM0700X Physician Assistant, Medical (Licence: NJ 25MP00298200) | |
| Enumeration Date | 2012-09-25 |
| Last Update Date | 2020-10-19 |