| NPI | 1972913986 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: FL PA9114681) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NY 017824) |
| 363A00000X Physician Assistant (Licence: NJ 25MP00399500) | |
| Enumeration Date | 2014-04-29 |
| Last Update Date | 2022-03-29 |