| NPI | 1538530597 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NJ 25MP00380500) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00380500) |
| 363AM0700X Physician Assistant, Medical (Licence: PA MA058164) | |
| Enumeration Date | 2015-10-15 |
| Last Update Date | 2024-10-03 |