| NPI | 1912168097 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical (Licence: NJ 25MP00206100) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 010694) |
| Enumeration Date | 2008-06-20 |
| Last Update Date | 2021-04-20 |