| NPI | 1578004164 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NJ 25MP00727800) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: GA 9832) |
| 363AS0400X Physician Assistant, Surgical (Licence: CA PA54356) | |
| 363A00000X Physician Assistant (Licence: CA PA54356) | |
| Enumeration Date | 2017-03-15 |
| Last Update Date | 2024-03-13 |