| NPI | 1578502779 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 015279) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: 1098952) |
| 2255A2300X Specialist/Technologist, Athletic Trainer | |
| 363A00000X Physician Assistant (Licence: NJ 25MP00331900) | |
| Enumeration Date | 2006-06-05 |
| Last Update Date | 2016-03-09 |