| NPI | 1720113350 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MA053964) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00175900) |
| Enumeration Date | 2007-02-23 |
| Last Update Date | 2019-02-26 |