| NPI | 1043848229 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207N00000X Dermatology (Licence: FL 18932) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: VA 0102209822) |
| 207ND0101X Dermatology, MOHS-Micrographic Surgery (Licence: WV 4821) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2020-04-01 |
| Last Update Date | 2025-12-08 |