| NPI | 1811491400 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: PA MA059724) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: PA MA059724) |
| 363AM0700X Physician Assistant, Medical (Licence: NJ 25MP00649700) | |
| Enumeration Date | 2018-03-20 |
| Last Update Date | 2023-11-16 |