| NPI | 1124693288 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program (Licence: FL OS22349) | 
| Additional Taxonomies | 207N00000X Dermatology (Licence: MI 5151015061) | 
| Enumeration Date | 2021-05-21 | 
| Last Update Date | 2025-06-30 |