| NPI | 1679545750 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA051206) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00106100) |
| Enumeration Date | 2006-02-03 |
| Last Update Date | 2025-01-09 |