| NPI | 1528499555 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NJ 25MP00481600) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NJ 25MT00155300) |
| 363AS0400X Physician Assistant, Surgical | |
| Enumeration Date | 2013-12-02 |
| Last Update Date | 2023-11-27 |