| NPI | 1720348295 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NJ 25MP00320400) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 015556) |
| Enumeration Date | 2012-05-18 |
| Last Update Date | 2025-02-20 |