| NPI | 1699090993 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: PA MA060559) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: PA TEI002569) |
| 363A00000X Physician Assistant (Licence: NJ 25MP00409400) | |
| Enumeration Date | 2010-03-30 |
| Last Update Date | 2022-03-14 |