| NPI | 1922623115 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NJ 25MP00576900) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ PA-GTL-20-00749) |
| Enumeration Date | 2020-06-12 |
| Last Update Date | 2020-10-22 |