| NPI | 1710969597 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9101788) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: DE C5-0012026) |
| 363A00000X Physician Assistant (Licence: NJ 25MP00052700) | |
| 363A00000X Physician Assistant (Licence: PA MA002676L) | |
| Enumeration Date | 2005-11-16 |
| Last Update Date | 2024-04-11 |