| NPI | 1720310790 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA0002698-L) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00086700) |
| 363A00000X Physician Assistant (Licence: NY 009075-1) | |
| Enumeration Date | 2010-02-02 |
| Last Update Date | 2010-02-02 |