| NPI | 1568754570 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NJ 25MP00353600) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: OH 003258) |
| 363A00000X Physician Assistant (Licence: IL 085.004019) | |
| 363A00000X Physician Assistant (Licence: CT 23.003041) | |
| 363A00000X Physician Assistant (Licence: NY 017087) | |
| Enumeration Date | 2011-05-09 |
| Last Update Date | 2015-04-22 |