| NPI | 1962194431 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363AM0700X Physician Assistant Medical (Licence: NJ 25MP00784900) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: NJ 25MP00784900) |
| Enumeration Date | 2023-05-23 |
| Last Update Date | 2024-01-22 |