| NPI | 1558871400 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA062133) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NJ 25MP00451000) |
| Enumeration Date | 2017-10-05 |
| Last Update Date | 2025-05-16 |