| NPI | 1578122636 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA064787) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NJ 25MP00523900) |
| Enumeration Date | 2019-06-11 |
| Last Update Date | 2023-10-24 |