| NPI | 1811385776 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 001006432) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00362300) |
| Enumeration Date | 2014-12-30 |
| Last Update Date | 2021-03-26 |