| NPI | 1720012206 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant Surgical (Licence: NJ 25MP00039000) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NJ 25MP00039000) |
| 363A00000X Physician Assistant (Licence: NJ 25MP00039000) | |
| Enumeration Date | 2006-07-10 |
| Last Update Date | 2023-12-22 |