| NPI | 1669916557 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: PA OA004644) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00412000) |
| Enumeration Date | 2016-12-12 |
| Last Update Date | 2024-09-08 |