| NPI | 1518567601 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NJ 25MP00588500) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: MA PA101814) |
| 363AM0700X Physician Assistant, Medical (Licence: NJ 25MP00588500) | |
| Enumeration Date | 2020-10-28 |
| Last Update Date | 2025-10-14 |