| NPI | 1629441696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NJ 25MP00518300) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA058011) |
| 363AM0700X Physician Assistant, Medical (Licence: PA OA003706) | |
| Enumeration Date | 2015-11-12 |
| Last Update Date | 2023-06-29 |