| NPI | 1154436830 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207N00000X Dermatology (Licence: OR OR MD12188) |
| Additional Taxonomies | 207N00000X Dermatology (Licence: WA WA MD00035021) |
| Enumeration Date | 2006-08-20 |
| Last Update Date | 2007-07-09 |