| NPI | 1700822111 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA OA002004) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00130500) |
| 363A00000X Physician Assistant (Licence: PA MA052005) | |
| Enumeration Date | 2006-06-22 |
| Last Update Date | 2022-08-30 |