| NPI | 1679558522 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NJ 25MP00435000) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 007507) |
| Enumeration Date | 2005-12-14 |
| Last Update Date | 2025-09-22 |