| NPI | 1780643940 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NJ 25MP00095200) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NY 5620234) |
| Enumeration Date | 2006-03-17 |
| Last Update Date | 2009-02-03 |