| NPI | 1811214638 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AS0400X Physician Assistant, Surgical |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: NJ 25MT00153100) |
| Enumeration Date | 2010-05-03 |
| Last Update Date | 2023-03-10 |