| NPI | 1972914935 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MD C05403) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: PA MA056843) |
| 363A00000X Physician Assistant (Licence: NJ 25MP00335400) | |
| Enumeration Date | 2014-05-13 |
| Last Update Date | 2014-12-17 |