| NPI | 1720004245 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: AZ 3397) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00155600) |
| 363AM0700X Physician Assistant, Medical (Licence: AZ 3397) | |
| Enumeration Date | 2006-07-15 |
| Last Update Date | 2013-04-16 |