| NPI | 1891215562 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NY 021092) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NJ 25MP00583900) |
| Enumeration Date | 2017-06-23 |
| Last Update Date | 2021-01-29 |