| NPI | 1073254256 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207N00000X Dermatology (Licence: MS 31820) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: MS 31820) |
| Enumeration Date | 2022-04-05 |
| Last Update Date | 2026-07-09 |