| NPI | 1942567524 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 015558) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00395900) |
| Enumeration Date | 2012-04-19 |
| Last Update Date | 2016-11-27 |