| NPI | 1750301115 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NJ 25MP00046300) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NY 003950) |
| Enumeration Date | 2006-07-20 |
| Last Update Date | 2025-08-28 |