| NPI | 1780254995 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NJ 25MP00628800) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NJ 25MP00628800) |
| Enumeration Date | 2021-06-29 |
| Last Update Date | 2025-04-29 |