| NPI | 1508682568 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 032974) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00898100) |
| Enumeration Date | 2024-11-25 |
| Last Update Date | 2024-11-25 |