| NPI | 1184011744 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 207N00000X Dermatology (Licence: MN 67857) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0101261323) |
| Enumeration Date | 2015-04-22 |
| Last Update Date | 2021-06-15 |