| NPI | 1770115743 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: PR 309-P.A.) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NJ NJDCATEMP-011832) |
| Enumeration Date | 2020-02-07 |
| Last Update Date | 2020-04-17 |