| NPI | 1760467294 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NJ 25MP00016400) | 
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: NJ 25MP00016400) | 
| 363A00000X Physician Assistant (Licence: MD C0002239) | |
| Enumeration Date | 2005-12-07 | 
| Last Update Date | 2025-04-07 |