| NPI | 1770518607 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NJ 25MP00497900) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: CT 000557) |
| Enumeration Date | 2006-07-11 |
| Last Update Date | 2019-10-02 |