| NPI | 1609343318 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PA MA060466) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NJ 25MP00495400) |
| Enumeration Date | 2018-10-31 |
| Last Update Date | 2019-10-28 |