| NPI | 1750590451 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical (Licence: NJ 25MP00102600) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 005884) |
| Enumeration Date | 2007-05-21 |
| Last Update Date | 2007-07-08 |