| NPI | 1578270450 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9118839) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00748200) |
| Enumeration Date | 2022-11-01 |
| Last Update Date | 2024-06-16 |