| NPI | 1780892695 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: FL PA9113366) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9113366) |
| 363AM0700X Physician Assistant, Medical (Licence: NJ MP000580) | |
| Enumeration Date | 2007-05-21 |
| Last Update Date | 2023-04-12 |