| NPI | 1932574340 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: PA MA057873) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00709400) |
| Enumeration Date | 2015-12-10 |
| Last Update Date | 2022-09-14 |