| NPI | 1750577011 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA055468) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 9797) |
| 363A00000X Physician Assistant (Licence: NJ 25MP00207300) | |
| Enumeration Date | 2007-09-20 |
| Last Update Date | 2018-03-17 |