| NPI | 1912336702 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NJ 25MP00624900) |
| Additional Taxonomies | 363AS0400X Physician Assistant, Surgical (Licence: NJ 25MP00624900) |
| Enumeration Date | 2013-11-02 |
| Last Update Date | 2021-08-12 |